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April 2013

Labial Stenotrophomonas Presenting as Lip Nodules in an Immunocompromised Host

Author Affiliations

Author Affiliations: Department of Pathology and Laboratory Medicine (Dr Xu), Department of Medicine, Infectious Disease Division (Dr Schuster), and Department of Dermatology (Drs Sobanko, Vittorio, Rosenbach, and Wanat), University of Pennsylvania, Philadelphia. Ms Hartman is a medical student at the Perelman School of Medicine, University of Pennsylvania.

JAMA Dermatol. 2013;149(4):495-497. doi:10.1001/jamadermatol.2013.2483

We present an unusual case of Stenotrophomonas maltophilia infection manifest as lip nodule in a patient with aplastic anemia. While S maltophilia may colonize the skin and mucosa, bacteremia indicates true infection and requires targeted therapy.

A 65-year-old woman with a history of sarcoidosis developed aplastic anemia and was treated with antithymocyte globulin, cyclosporine, and methylprednisolone sodium succinate (Solu-Medrol; Pfizer). Despite treatment, she developed intermittent neutropenic fevers. Blood cultures initially were positive for vancomycin-resistant enterococcus. Treatment with intravenous linezolid and meropenem was initiated, resulting in negative blood cultures. After 3 weeks, her neutropenic fevers returned. Repeated blood cultures grew S maltophilia for 3 days, which was susceptible to treatment with trimethoprim-sulfamethoxazole (TMP-SMX). She was treated with a 2-week regimen of oral TMP-SMX and had continued fevers despite negative blood cultures. During this time, her aplastic anemia treatment was changed from cyclosporine to alemtuzumab. Three weeks after the completion of treatment with TMP-SMX, she again developed S maltophilia bacteremia over 4 days, and therapy with oral TMP-SMX was reinstituted. Blood cultures from 2 peripherally inserted central catheters tested positive for S maltophilia, but these findings were attributed to contamination.